What is Cervical Spondylosis?
Cervical spondylosis is an age related condition in which there are degenerative changes that affect the vertebra of the neck region. Cervical spondylosis can cause stiffness, discomfort, and headaches related to neck pain.
It affects the joints mainly vertebral bodies and cushion pad in between the vertebra (inter-vertebral discs) there is wear and tear of the cartilage and the bone.
Since it’s an age related condition some people who have it may not show any symptoms but in others they may represent pain, stiffness, even tingling numbness (pins and needles) radiating or going down their hand {1}.
What are the causes of Cervical Spondylosis?
There are numerous causes which may lead to cervical spondylosis mainly age related changes like bony spurs and wear and tear at the cervical spine.
In about 10% of patients, cervical spondylosis is due to bony anomalies present at birth, blocked vertebrae, malformed laminae (vertebral bone part) that place undue stress on adjacent inter-vertebral discs {2}.
The inter-vertebral disc is made of outer firm surface called annulus fibrosis and the inner fluid called the nucleus pulposis. Changes at the inter-vertebral discs contribute the spondylosis at the cervical vertebra.
Narrowing of the disc (due to age) or disc herniation of the nucleus pulposis may lead to compression of the spinal cord and nerves, resulting in symptoms such as arm numbness as well as pain that radiates down an arm.
Ligament stiffness at the cervical inter-vertebral joints leads to the changes at the cervical vertebrae.
Overuse of the neck muscles like prolonged sitting in front of laptop or desktop, prolonged usage of phone, heavy lifting that may put extra load on the cervical spine leading to early wear and tear.
Injury at the neck like whiplash injury can also lead to this condition {3}.
What are the symptoms?
Pain and tenderness present in the neck and shoulders, along with painful neck movements.
Stiffness in the muscles around the neck and shoulders may be present in the acute cases.
Pain may sometimes radiate to an entire arm associated with tingling and numbness.
Pain may be present while coughing or sneezing.
In some cases headaches mainly caused due to arterial insufficiency to the brain due to cervical vertebra changes {4}.
How to diagnose it?
Physical examination along with the detailed history of onset and the progression of symptoms can be diagnostic criteria for cervical spondylosis.
The McKenzie's Mechanical Diagnosis and Therapy (MDT) can be used as a diagnostic tool along with co-relation of the patient’s symptoms by x rays and MRI (Magnetic resonance imaging) {5}.
In the cases where the pain radiates down to the hand, an electromyogram (EMG) and nerve conduction studies are used to check nerve’s electrical activity and the speed and strength of the signals a nerve sends {6}.
How to manage cervical spondylosis?
The treatment strategy for cervical spondylosis depends on the severity of a patient’s signs and symptoms.
The main line of management when it comes to cervical spondylosis is to manage the symptoms of the patient including to relieve pain, improve functional ability in day-to-day activities, and prevent permanent injury to neural structures.
In the acute phases of the neck pain episode Non-steroidal anti-inflammatory drugs (NSAIDs), oral steroids, muscle relaxants, anticonvulsants can be prescribed for pain relief {7}.
Importance of sleeping postures along with usage of a firm pillow should be inculcated to the patient, workplace ergonomics and modification for laptop and desktop users.
Postures which will put stress on the neck should be avoided e.g Text neck syndrome which is caused by prolonged usage of smart phone; a study suggests that neck flexion angle between 0° and 15° when using their smart phone. This would reduce neck muscle activity and the risk of developing neck disorders associated with smart phone use {8}.
Surgical management in the severe or progressive cases of cervical myelopathy, as well as those with persistent neck pain or cervical radiculopathy including continues tingling and numbness. X ray or MRI co- relating with the clinical representation of patient’s condition including severe degenerative changes at the cervical spine including disc herniation and bony spurs {9}.
Physiotherapy treatment should individualize to each patient considering their mechanical loading on the neck in their ADLs or any advance activities, it generally includes rehabilitation exercises, proprioceptive re-education, manual therapy and postural education.
McKenzie's Mechanical Diagnosis and Therapy (MDT) to improve the posture of the neck by doing periodic corrective movement with proper directional preference in the patients of cervical spondylosis or neck pain e.g chin tucks.
A study suggests that with the help Mechanical Diagnosis and Therapy (MDT) providers understand the common DP constructs encountered in routine clinical practice and their relation to pain and disability outcomes for patients with cervical spine challenges{10}.
Soft tissue mobilization or Deep tissue release therapy to muscles of the neck, shoulder and upper arm. Superficial mobility muscles around the neck and shoulders go into tightness which causes abnormal mechanical loading on the neck {11}.
Exercises may include deep cervical flexor strengthening, scapular strengthening, stretching of the chest muscles via isometric contraction of flexor of extensor muscles to encourage the mobility of the neural structures of the upper extremity {11}.
Neurodynamic evaluation and treatment along with manual techniques including mulligan mobilizations for cervical radiculopathy has proven effective. A study suggests that ‘patients treated with Spinal Mobilization with Arm Movement along with neurodynamic and manual traction had better outcome compared to those who only got neurodynamic and manual traction’{12}.
Resistive exercises for upper back and shoulder to obtain high levels of muscle activation along with patient’s education in maintaining a proper posture and avoiding sustained postures is a crucial part in managing cervical spondylosis {13}.
We Physiotherapists may not eradicate the condition but can always help the cervical spondylosis patient to manage their pain episodes by formulating targeted individualized program focused on individual muscle strength.
References-
1] Iyer A, Azad TD, Tharin S. Cervical Spondylotic Myelopathy. Clin Spine Surg. 2016;29(10):408-414. doi:10.1097/BSD.0000000000000397.
2] McCormack BM, Weinstein PR. Cervical spondylosis. An update. West J Med. Jul-Aug 1996;165(1-2):43-51.
3] Rydman E, Kasina P, Ponzer S, Järnbert-Pettersson H. Association between cervical degeneration and self-perceived nonrecovery after whiplash injury. Spine J. 2019;19(12):1986-1994. doi:10.1016/j.spinee.2019.07.017.
4] Fredriksen TA, Antonaci F, Sjaastad O. Cervicogenic headache: too important to be left un-diagnosed. J Headache Pain. 2015;16:6. doi:10.1186/1129-2377-16-6.
5] Luetchford S, Declich M, Tavella R, Zaninelli D, May S. Diagnosis of cervical and thoracic musculoskeletal spinal pain receptive to mechanical movement strategies: a multicenter observational study. J Man Manip Ther. 2018;26(5):292-300. doi:10.1080/10669817.2018.1505328.
6] Castelein B, Cools A, Parlevliet T, Cagnie B. Are chronic neck pain, scapular dyskinesis and altered scapulothoracic muscle activity interrelated?: A case-control study with surface and fine-wire EMG. J Electromyogr Kinesiol. 2016;31:136-143. doi:10.1016/j.jelekin.2016.10.008.
7] Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One. 2017;12(6):e0178621. Published 2017 Jun 22. doi:10.1371/journal.pone.0178621.
8] Namwongsa S, Puntumetakul R, Neubert MS, Boucaut R. Effect of neck flexion angles on neck muscle activity among smartphone users with and without neck pain. Ergonomics. 2019;62(12):1524-1533. doi:10.1080/00140139.2019.1661525.
9] Liu H, Yue L, Chen SL, et al. Beijing Da Xue Xue Bao Yi Xue Ban. 2018;50(2):347-351.
10] Yarznbowicz R, Tao M. Directional preference constructs for patients' neck pain in the absence of centralization. J Man Manip Ther. 2019;27(4):229-236. doi:10.1080/10669817.2019.1568660.
11] Ibrahim M. Moustafa and Aliaa A. Diab, Multimodal Treatment Program Comparing 2 Different Traction Approaches for Patients With Discogenic Cervical Radiculopathy: A Randomized Controlled Trial, Journal of Chiropractic Medicine (2014) 13, 157–167.
12] Shafique S, Ahmad S, Shakil-Ur-Rehman S. Effect of Mulligan spinal mobilization with arm movement along with neurodynamics and manual traction in cervical radiculopathy patients: A randomized controlled trial. J Pak Med Assoc. 2019;69(11):1601-1604. doi:10.5455/JPMA.297956.
13] Andersen LL, Andersen CH, Mortensen OS, Poulsen OM, Bjørnlund IB, Zebis MK. Muscle activation and perceived loading during rehabilitation exercises: comparison of dumbbells and elastic resistance. Phys Ther. 2010;90(4):538-549. doi:10.2522/ptj.20090167